Ambulance delays during power cut possibly contributed to man’s death, coroner rules | NHS
A family has welcomed a coroner’s conclusion that ambulance delays likely contributed to the 2019 death of a man who endured “years of distress trying to find answers”.
Peter Coates’ family said they faced “delays and resistance” from the regional ambulance service as they tried to discover the full circumstances of his final moments.
Kellie Coates, Peter’s daughter, said: “For us, this process has not only been about managing pain, but also about challenging a system that seems more focused on self-preservation than acknowledging and learning from errors in its processes.”
Coates died in the early hours of March 14, 2019, at the age of 62, after a power outage stopped the electrical equipment he needed to breathe at home.
An inquest in Middlesbrough heard Coates, from Redcar, rang 999 and an ambulance was sent by the North East ambulance service (NEAS). However, the same power outage prevented the emergency vehicle from passing through the electric gates at the station.
On the way to work, a second ambulance stopped to refuel. When the ambulance crew arrived they could not immediately find the key safe needed to get in, even though Coates had given the details when he called.
Coroner Paul Appleton said Friday that ambulance delays “probably” contributed to Coates’ death.
The incident was treated as a category two ambulance call, which was the second highest priority because Coates was able to speak. The target is to reach 90% of the incidents in the second category within 40 minutes. For category one calls, the 90% target is 15 minutes.
Appleton stated that he would send a report to NHS England on preventing future deaths and expressed his concern that there was a gap between the first and second categories, stating that “patients who require urgent intervention but do not have cardiac or respiratory arrest” cannot be considered as the first category.
Coates, who worked at Redcar British Steel throughout his working life, had lung cancer. Although he went into remission, he never regained full health and was soon diagnosed with chronic obstructive pulmonary disease (COPD). He relied on the Cpap machine and portable oxygen bottles in his bedroom to help him breathe.
The inquest heard Coates was unable to access his portable oxygen in the minutes after the power outage on March 14, 2019. In an audio recording of his 999 call played to the court, Coates said: “I’m breathing, but I’m just breathing. You’d better find someone quick.”
Even though he lived far from the ambulance station, due to the same power outage, the automatic doors would not open and the station staff did not know how to close them manually.
Paul Elstob, from the NEAS operational leadership team, told the investigation in January that ambulance staff were now briefed on how to use door controls manually.
The second ambulance was sent to Coates’ home from a station further away, but they were allowed to stop at a petrol station en route, despite having almost half a tank of fuel.
The coroner said it took the crew four minutes to refuel and fuel was all that was purchased.
By the time paramedics entered the home, 47 minutes after Coates called for help, Coates was already dead.
Coates’ family only learned of the circumstances of his death when the tipster submitted a dossier. Information to the Sunday Times Three years later it emerged that the ambulance service had covered up its failures.
NEAS deputy chief executive Karen O’Brien said the service had made changes to its processes. He said: “This is a tragic incident which we understand has deeply affected the family and NEAS staff involved. We are truly sorry that we were not able to respond to Mr Coates’ appeal more quickly.”
“We recognize that the time it has taken to reach this conclusion has impacted Mr. Coates’ loved ones and we would like to once again extend our sincere condolences to his family on this sad loss.”
